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DENISE KENNEDY: Hello, everyone. Welcome, and thank you for
attending our VA Mobile Health Discussion Series webinar. My name is
Denise Kennedy, and I'm going to run through a few brief technical
reminders before we begin the discussion about the Remote Veterans
Apnea Management Platform – also known as REVAMP.
Your phone lines are muted. We will be taking questions through the chat
feature. If you experience any technical difficulties, please use the chat
function that is available to you at the right of your screen. To respect
everyone's schedules we'll keep this moving so the session ends on time.
Today we welcome Dr. Samuel Kuna from the Philadelphia VA Medical
Center. He's the sleep center director, and is also the clinical lead on
REVAMP. We also welcome Priyanna Mehta, working on REVAMP's
quality assurance.
As I mentioned before, if you have any questions for our presenters please
use the chat feature. If we don't get to your question, we will send out an
email following this webinar with any relevant answers. To download the
presentation, please click on the file name below the chat screen. With that,
I'll turn it over to you, Dr. Kuna.
DR. SAMUEL KUNA: Well, thank you very much. REVAMP is, as
mentioned, the Remote Veteran Apnea Management Platform, and it's a
personalized interactive web application that we're developing for Veterans
with obstructive sleep apnea. So REVAMP has a Veteran-facing platform
that collects information from the patient and shares that information with
the Veteran. REVAMP also has a practitioner-facing platform where
practitioners can review the data that was entered by the patient and use it
to conduct patient management. The goals of REVAMP are to improve
access to care, standardize delivery of care, increase staff efficiency and
allow the VA to assess patient-centered outcomes-- who is using CPAP
and determine benefits they get from the treatment. Then, we compare
REVAMP outcomes across programs to improve delivery of care.
We've performed some initial pilot testing that's demonstrated the potential
of REVAMP to lower costs, improve patient use of CPAP treatment and
improve the health care experience of patients with sleep apnea.
We believe that REVAMP will fulfill an important need. OSA is recognized
as the third most common chronic condition in the Veteran population, and
patient demand is growing rapidly. Sleep care utilization is averaging a 16
percent growth annually over the last five years, and this is threefold
greater than what is being seen in primary care. That patient demand has
overwhelmed VA sleep programs and restricted Veterans' access to care.
In May of 2016 we had over 21,000 open sleep consults, and just six
months later that number rose to almost 31,000. Many Veterans live too far
away from a sleep center to gain access to the specialty care, and so they
don't even try. In FY '16, the VA incurred a cost of $183 million in CPAP
equipment and supplies, so we have a growing patient need for these
services.
To access REVAMP, Veterans will use their DS Logon and access it
through the VA mobile app store using their iPhone, iPad or other mobile
device. The practitioner will access REVAMP from the VA-networked
computers using their PIV card. Our goal is to have REVAMP in field
testing at 10 sites by early March.
Current care to delivery of Veterans with obstructive sleep apnea is
inefficient, and it doesn't take advantage of existing technologies. Veterans
typically must drive to a VA facility-- which is often hours away-- taking time
off from work and school. There they complete paper questionnaires, but
the information collected varies across the sites, and entering it manually
into CPRS is inefficient, and the documentation is often incomplete. When
Veterans with sleep apnea on CPAP treatment are seen in follow up, the
practitioner must often rely solely on patient reporting and does not have
access to the information from the patient's CPAP unit. The CPAP unit
would provide evidence of whether the patient is having trouble using the
treatment, and how well the treatment is working. That objective
information is essential for patient management and is often lacking. Next
slide.
REVAMP does away with these outmoded practices. By combining
REVAMP with existing Telehealth technologies Veterans with sleep apnea
can be diagnosed and treated without having to travel to a sleep center.
Veterans complete validated questionnaires on REVAMP that are reviewed
by the practitioner. By administering the questionnaires at intake and follow
up we can evaluate patient outcomes. The Veterans are mailed the
portable monitor for home testing, and watch videos on REVAMP
instructing them how to perform the test. Veterans diagnosed with sleep
apnea in the home sleep test can then be started on auto-adjusting CPAP
treatment. The information from the unit on patient use and treatment
efficacy is transmitted wirelessly to the REVAMP platform.
Both ResMed and Philips Respironics-- the major CPAP manufacturers
used in the VA-- have agreed to share the data on their servers and send it
to REVAMP, and agreements with other manufacturers are being pursued.
Veterans can view their PAP results on the REVAMP platform, and we
have evidence that this improves their use of treatment. Practitioners can
review the PAP data on the REVAMP to help patients so they have access
to the objective information.
A very innovative feature of REVAMP is that it auto populates templated
progress notes with the information that it collects from the patient. These
notes can be copied into CPRS, enabling complete accurate
documentation and saving practitioner time. REVAMP can also export
patient data to spreadsheets, allowing assessment of patient-centered
outcomes.
So with that overview I want to turn the presentation over to Priyanna
Mehta for a demonstration of the features in REVAMP.
PRIYANNA MEHTA: Thank you, Dr. Kuna. As Dr. Kuna mentioned, after
this overview I'm going to walk through a high level demonstration for you
of the patient and the provider's platform to see how they interact. The
patient will use single sign on externally to access the patient platform, and
the provider will use single sign on internally. As Dr. Kuna mentioned, a
practitioner will utilize a PIV card, as well as other options, and then the
patient can use Norton, DS Logon, et cetera. So for the sake of time, I will
not be showing that sign in process today but will instead begin with the
demonstration.
So beginning here, this is where the provider actually looks up the patient
so they may be registered in REVAMP. Inside the provider application is a
patient look-up feature. Here the provider will enter the first name, last
name and social security number of the patient. This look up feature then
goes out to the Master Veteran Index-- or MVI-- to locate and pull the
patient's demographic information down.
Once the patient's information has been found through MVI, the provider
will see a screen, such as this, with the patient's demographic information.
You can see a lot of the fields have already been pre-populated with the
information available from MVI. Any additional information can be entered
by the provider and modified to correct any errors. There are a number of
required fields needed to register the patient. From here, the provider will
use the Save button-- in the upper left next to the magnifying glass-- and by
saving, the patient has now been added as a patient to REVAMP.
Once the patient has been added to REVAMP they will receive a welcome
email. That's not shown here, but the patient gets an email message letting
them know that they are now a part of the REVAMP program; that will
direct them to the patient platform. There is a link provided there so that
they can go straight to the platform from the email, and when they arrive
here at the platform you can see that they will log in. And when they log in
this is the first screen that they will see – this is known as the intake
process.
As a new patient logging into the patient platform for the first time, there are
a series of steps where they will confirm their profile information, watch a
brief video and then complete the validated questionnaires that Dr. Kuna
mentioned earlier. This is the first page of the intake process, known as
“My Profile.” Here useres click through a number of steps using the Next
button.
As the patient clicks Next once we have verified all their profile information
you can see at the top of this screen there has a green check mark, letting
the patient know that they've completed the intake process. And now, we
are on the second step known as “About REVAMP.” Here the patient will
watch a brief video that gives them an introduction to REVAMP, and why
they have been referred to this program and how it can help them with
sleep apnea.
Once they have viewed the video, and clicked Next, they will arrive at the
third and final step of the intake process. This is called, “My Sleep Health.”
Here, they will complete a series of validated questionnaires that will
provide the practitioner a baseline. Here you can see there are a number of
questionnaires listed, and all of these questionnaires must be completed in
order for the patient to complete the intake process.
OK. Going to the next slide, here's an example of the first questionnaire,
known as the initial information questionnaire. This is just a view to give
you an idea of what a questionnaire may look like. The patient would go
through, make any selection, click Submit, and then after each
questionnaire they are returned to this page, which will show a check mark
next to the left.
But once all the questionnaire have been completed-- as you can see here,
they all have a check mark to the left-- the patient would click Next, and
then arrive at this screen here, just letting them know that they have
successfully completed the account set up. They are informed their
provider has been notified and will contact them with any next steps.
Once the patient completes the intake process the provider has a baseline
of information from the completed questionnaire that the patient did in the
platform. Here you can see in the provider platform the practitioner can
review each of the questionnaires, and review the responses that the
patient gave for those questionnaires. Here is an example of the initial
information questionnaire with the responses that the patient provided.
They can export this data, as well.
Okay, so once the provider has reviewed all of the patient’s questionnaire
data and determined they should perform a sleep study -- particularly a
home sleep study -- they can go to the sleep study section of the platform.
Here they can actually schedule the study for the patient. They would enter
in a date scheduled and select the study type. Once they do this, the
patient receives a notification that they have been scheduled for this study.
This notification by email will also direct them back toward the patient
platform where they can go to a sleep testing section in the platform. This is
where they will be able to see a video that will tell them how they can
complete their study at home, for example. We see here the NOX-T3
monitor and recorder. So the patient will watch this video, perform the study
at home and send the recorder back to their clinic.
Once the provider receives the recorder in the mail and reviews the results
of the study, they decide if the patient has a diagnosis of sleep apnea and if
the patient would need a CPAP machine assigned to them for treatment.
Here they can access the PAP machine area of the provider platform,
which is where they assign the patient the device, if appropriate.
To do that they need a serial number and a manufacturer-- which, in our
initial release, we are working with ResMed and Philips, and have plans to
add others in the future. By assigning the device here, this allows REVAMP
to retrieve the data from either ResMed or Philips as the patient uses the
device.
Now we return back to the patient side of the platform.
Here the patient has been using the device regularly. They have access to
a section in the patient platform called “Treatment Results.” This is where
they can get their PAP data, such as this section here, which is known as
My PAP, which shows them their PAP usage. The display you see here
now is showing a last night view – it shows the patient how much they used
their PAP machine for the previous night. It shows the patient was using
the device nine hours and 40 minutes. They can hover over the bars
underneath to get additional information on when they had the mask on,
when they took it off, et cetera.
The next screen that you see here is the “My Mask” section, and this will
show the patient data on mask leaks. A happy face tells the patient that
their mask leakage was in an acceptable range, or below 24 litres per hour.
And this would indicate that they're having a good mask fit. If it was 24
litres per hour, then it would show an unhappy face and then provide the
patient additional information on where they can get help on mask fit
improvement.
I would like to mention that the AHI screen-- which I am not showing here--
also displays in a similar manner, and it uses a threshold of 10 apnea
hypopnea events per hour to determine if the patient needs to review that.
It would also show a happy face if it's below that, and a not so happy face
it's above that.
As the patient is able to access and see their data in the patient platform,
the provider may also review the patient's PAP data in their platform. Here
you can see a bar graph that shows the treatment adherence data per
patient, showing how much they are using their PAP device. This is a
display that shows the past seven days of data. The provider can also
change the view to set it to specific dates, to view last month. Here is
[INAUDIBLE] graphics available to the provider to review the patient's data.
And this is an apnea events type graph, which shows the AHI broken down
by event type. This can also be modified to view by different time ranges--
last week or last month-- and not shown here is some additional data,
including the PAP patterns of use. They show when the patient was
wearing the mask, when they took it off-- a graph that shows the AHI on its
own, as well as one that will display [INAUDIBLE].
OK. So that concludes the overall demonstration and walk through of the
two platforms today. I would turn it over now to Dr. Kuna to give his closing
remarks for the presentation.
DR. SAMUEL KUNA: Thanks. So we're very excited about this new
approach to management of Veterans with sleep apnea. And we see the
immediate gains as being a rapid expansion of home sleep testing. that rely
on getting things out to the patients’ homes so they don't have to come to
the sleep center, reducing costs to the VA and improving access.
Rapid expansion of sleep telehealth: REVAMP is going to collect
information from the patient, and share that with the patient and the
practitioner. But if you combine that platform with existing sleep Telehealth
technologies you can develop a clinical pathway, which allows you to reach
Veterans without them having to travel to a sleep center. And then we see
this as possibly being applied in a hub-spoke model where, perhaps, sleep
centers that have more resources can provide that to VA medical centers
that do not have sleep resources to meet the demand they're facing.
The bottom line is that we want REVAMP to improve Veteran access to
care for their sleep disorders, and see this as moving beyond sleep apnea.
This platform is something that could be applicable to the treatment of
Veterans with insomnia and other chronic medical conditions.
We're just bringing up a slide in which we would like to acknowledge the
support that we've received, and the team that has been working closely
together in the development of this project. The original supporter was the
VA Center for Innovations, led by Patrick Littlefield. The core REVAMP
team members have been myself, Dr. Katy Sarmiento, Carl Stepnowski at
the San Diego VA and Blake Henderson as the project manager. The IT
team that we have been working with to develop the web platform has been
ASM research, collaborating with Intellica Corporation. The business owner
has been Connected Care, led by Dr. Kathy Frisbee and Dr. Neil Evans.
We've had key collaborators through the Office of Specialty Care; Claibe
Yarbrough, the National Director of Pulmonary Critical Care and Sleep;
prosthetics with Penny Nechanicky and Lou Beck; and then also Dr. Kevin
Galpin in Telemedicine.
We want to thank all of these people for their support, and for working
together so closely.
DENISE KENNEDY: Excellent. Thank you so much. We have quite a bit of
questions popping up here, which is great. So I'm just going to start at the
beginning and I'll tee them up to you Dr. Kuna. And if you want to pass that
along, and defer that answer, please go ahead and do so.
The first question: is the provider assigning the device and manually
entering the serial number?
DR. SAMUEL KUNA: Yes. That would be done by the provider who has
access to the REVAMP platform. So they would need to have the serial
number of the device in order to link REVAMP to the manufacturer's server.
DENISE KENNEDY: Excellent. And the next one: Is there a specific HST
device that will be the standard? Or is it any HST device that may already
be in use?
DR. SAMUEL KUNA: It's the latter. So people can use whatever home
portable monitor they are currently using. We did not want to be
prescriptive in the development of the platform. We wanted this to be able
to be used within whatever clinical program that was already existing, and
that this would then increase the efficiency of that program. That was why
we felt it was so important to have as many of the PAP manufacturers on
the platform as possible. So that practitioners not only did not have to go
from one manufacturer's website to another, but that also they could use
whatever PAP machine they wanted for taking care of their patients.
DENISE KENNEDY: Excellent. Thank you. And the next question is: are
the PAPs in the system all wireless?
DR. SAMUEL KUNA: Yes. There would need to be a wireless transmission
of the data from the patient's home to the manufacturer's server, and then
the manufacturers are sending that, on a daily basis, to the REVAMP
platform. And both Philips Respironics and ResMed now have wireless
transmission as a standard part of their current model line.
DENISE KENNEDY: Great. Excellent. And the next question is a two part
question here. So the first part is, what kind of info is sent within the
automated emails from the REVAMP system? And the second part of that--
because I think the second part is important too-- is, how are these emails
compliant with the privacy/security standards as this involves active patient
treatment info?
DR. SAMUEL KUNA: So that's a great question. The email reminders are
just reminding patients about appointments, things that they need to do. If
they have not filled out questionnaires in a timely manner they would get a
ping reminding them to do that. All of this is going through very
comprehensive VA security oversight. The platform itself will be within the
VA firewall. So we are confident that, going through that process, we are
assuring the privacy and security of the patients.
DENISE KENNEDY: All right. We're just reconciling questions here as
there's a lot coming in. So can REVAMP be used for in-lab PSG
scheduling?
DR. SAMUEL KUNA: No. It would not be used for in-lab scheduling. So it's
really an outpatient system for keeping people out of the sleep center. We
recognize that not everyone will be able to use REVAMP, and there are
patients with complicated medical problems who will need to come into a
sleep center. So we see REVAMP working in parallel, but not as a
substitute for in-laboratory testing.
DENISE KENNEDY: OK, great. OK. So here is a question. Can you tell us
how this relates to our ever-growing compensation and pension
population?
DR. SAMUEL KUNA: So this is an important question. Certainly, I think
some of the demand that we are seeing in sleep medicine for diagnosis
and treatment of sleep apnea is related to the fact that people do want to
get service connected for the condition. I think there are measures that we
need to be taking, although I don't think they're specifically related to
REVAMP.
For example, perhaps ensuring there is a chain of custody on the portable
monitors that are being used to ensure the Veteran is actually doing the
testing at home. REVAMP simply facilitate the ability to address patient
demand, but it does not create a policy on how those patients should be
processed.
DENISE KENNEDY: Excellent. Thank you. So is there an initial 10 centers
that have been selected?
DR. SAMUEL KUNA: Yes. We have selected the 10 sites. They're ranging
across the country, and we've been meeting with them over the past year
in order to coordinate the initial rollout. We are hoping once REVAMP has
passed that test we will scale it up to include many other VA medical
centers with the goal of being a national platform.
DENISE KENNEDY: Okay. And then another question: How is the provider
notified when a patient's info is ready for review?
DR. SAMUEL KUNA: We have a case management dashboard on
REVAMP where the practitioner can go and look to see the patients, and
what has been completed, and what is pending.
DENISE KENNEDY: Excellent. Thank you for that. Will this information be
brought back into the VA medical record? Or will the VA have a consult
entered to document for the patient?
DR. SAMUEL KUNA: Currently REVAMP does not talk with CPRS, but it
has been configured to do so in the future. Currently, the progress note is
generated within REVAMP by that automatic export that I mentioned. That
note needs to be copied and then pasted into the CPRS progress note. We
do very much want, in the future, to make that direct connection between
REVAMP and the electronic medical record.
DENISE KENNEDY: Excellent. Thank you. Are IT and Biomed on board for
this program?
DR. SAMUEL KUNA: Yes. We have been working with those departments,
and it's not something that is actually needed at a local level because it's
going to be available through the web and within the VA firewall. DENISE
KENNEDY: Excellent. And we have a question here that I feel we get quite
often on these calls. REVAMP is based primarily on electronics medium,
and there are patients that are not maybe savvy with using electronics. The
questioner is concerned that the patient may not understand how to apply
the HST device despite watching the video. What then?
DR. SAMUEL KUNA: So I think this can be addressed by, for example, the
clinical video teleconferencing. REVAMP is this platform which is collecting
data from the patient and sharing it with the patient practitioner. But if you
combine that with telehealth technologies, you greatly strengthen what can
be done. If a patient is having trouble in applying the sensors -- say the first
attempt has failed-- you can try again, and then ask that patient to go to a
local VA facility and set up a clinical video teleconference. And then, we
can show them how to do it over the video conferencing.
DENISE KENNEDY: Great. Thanks. And Dr. Kuna, I wanted to back to an
earlier question about whether or not any HST unit could be used. One of
the attendees here posed a question that the answer was that any PAP can
be used. Can any HST unit be used? Not being a practitioner, I'm not
exactly sure how to probe the answer there.
DR. SAMUEL KUNA: I'm sorry that I caused confusion with that answer.
Any home sleep test monitor can be used, and people would still be able to
use REVAMP. REVAMP does not exclude the use of any home sleep test
portable monitor. So whatever is being used, if it's a type three, type four--
regardless of the manufacturer-- it can be used with this platform. The
home test monitor does not integrate electronically with REVAMP, so we
currently do not have ways of bringing in the results from the home sleep
test monitor into the REVAMP platform. We have included in REVAMP
some very minimal information that the practitioner will need to manually
enter-- to give us the Apnea-Hypopnea index, for example, oxygen
saturation index-- so that we can monitor the severity of the patient, and tell
where we started in the patient management.
DENISE KENNEDY: Excellent. And the questions keep coming in, which
just shows the remarkable interest in this program. Moving right along, are
watchPAT devices accepted for this model? For REVAMP?
DR. SAMUEL KUNA: Yes. They are fine. So again, there is no direct link
between the REVAMP platform and the portable monitor that is used for
home sleep testing. The direct link is with the PAP machine. So the PAP
machine is talking, essentially, to the REVAMP platform, but there is no
such link with the home sleep test.
DENISE KENNEDY: Great. Does REVAMP need specific IT support to
initiate the process at the local VA level?
DR. SAMUEL KUNA: No, it does not.
DENISE KENNEDY: Excellent. And I think you answered the question
about the data and workload all going to CPRS. Currently that's not
supported. That's correct, right?
DR. SAMUEL KUNA: That is correct. We do not have a direct link at this
time between revamp and CPRS, but we have configured the platform so
that it will be able to do that in the future.
DENISE KENNEDY: Great. So there was more of a comment here, but I
wanted to bring it up because I think you might have a strong opinion of it
there. Someone says, if a center has no problem with patient access,
should we should stick with one to one visits and interactions? Any
thoughts on that?
DR. SAMUEL KUNA: Well, this is not a mandatory program, and it will be
offered to VA medical centers to improve staff efficiency. One of the things
that we've found to help with patient care during pilot testing is that it saved
a considerable amount of practitioner time to be able to use the REVAMP
platform, which auto populates the progress notes so the practitioner did
not have to manually enter all of that information. And even if there is no
specific access problem, I think everyone's looking for improved efficiency
that will give practitioners more time to take care of other patients.
DENISE KENNEDY: Excellent. Thanks. How were the patients initially
selected to start in the REVAMP platform? Did they go from a sleep
medical consult to the REVAMP by a sleep provider?
DR. SAMUEL KUNA: That is correct. So the way we did it with our first pilot
study was that when consults came in we asked patients during the triage
process if they had access to the internet. And those that did, we offered
them the opportunity to participate with the REVAMP platform. We had very
positive response from the patients from that experience.
DENISE KENNEDY: Excellent. Thank you. How are the HSTs being sent
and received? Is there a central system for this?
DR. SAMUEL KUNA: Oh, that's an excellent question. We would love to
see that happen, and we're working towards that. But currently, the way it
would be done is that the monitor would be mailed from the local VA
supporting REVAMP, and then mailing materials will be included where the
Veteran could return again by mail. We've been doing this at some of the
VA medical centers already and it's worked quite successfully. In the future,
we are hoping that a centralized location can be established that will allow
the monitors to go out and be returned through a centralized distribution
center.
DENISE KENNEDY: Excellent. And we have about 10 more questions to
go, so I hope you can get a sip of water, Dr. Kuna. You've just been
barreling through these, thank you so much.
DR. SAMUEL KUNA: Well, this is great. I'm glad we're getting such great
feedback.
DENISE KENNEDY: Excellent. Are most VA sleep centers shipping out
their own HST equipment, or contracting with home sleep test companies?
DR. SAMUEL KUNA: I think both are being done, and both would work
using the REVAMP platform. So again, it doesn't prescribe a particular
practice, it only tries to facilitate what practice is going on.
DENISE KENNEDY: Excellent. Thank you. And then, can patients access
this website through a tablet as well, and can the questionnaires be
performed by patients in their clinic?
DR. SAMUEL KUNA: Yes. I like that idea a lot. The answer is yes, the
patients can access the platform from a tablet. One of the thoughts or
suggestions has been that tablets might be available in the waiting rooms.
So the patients can fill out these questionnaires, and then they would be
available for the practitioners to see. So again, in that particular instance,
the patients are coming in to the sleep center, and are filling out the
questionnaires there, and are having an in-person encounter with the
practitioner. It doesn't have to be that the patient is at home and the
practitioner's in the sleep center, or in the VA facility. We tried to develop
this in to be flexible, so that it doesn't require a particular clinical pathway to
be used.
DENISE KENNEDY: Excellent. Thank you. OK. Moving right along here...
Does this replace EncoreAnywhere?
DR. SAMUEL KUNA: Well, EncoreAnywhere and AirView-- so
EncoreAnywhere is Philips Respironics' platform, and AirView is that of
ResMed-- and then Divelbiss and Fisher Paykel I believe also have their
platforms. REVAMP does not replace those, and it will not have as much of
the detailed information as would be available on the manufacturer's
platforms. But it will have the essential elements that are needed for
management. It will have the patient use, it will have the residual AHI, it will
have the information about the air leak from the circuit. If the practitioner
needs more detailed information, they can then go to the manufacturer's
platform in order to answer the question that they might have.
The value and importance of the REVAMP platform is that it is collecting
the data from all of the manufacturers-- and currently now the two major
manufacturers-- in the VA. So we have a single platform, and that then can
allow us to monitor what patients are doing across the VA. Then we don't
have to rely upon getting data out of Philips Respironics and ResMed. We
will have a national network in which we can look at how Veterans use their
PAP treatment and then compare to the functional outcomes on the
questionnaires that they are completing to look at patient-centered
outcomes. We see this as a very powerful tool for looking at many
questions that we have about how to best manage patients with sleep
apnea.
DENISE KENNEDY: Great. Thanks. And as a little bit of a follow up to that
we have one questioner that says, we've been unable to get permission to
use EncoreAnywhere at our VA. Will we be able to change the setting on a
patient's CPAP/BiPAP unit remotely through REVAMP?
DR. SAMUEL KUNA: No. You will not be able to change the settings on the
patient's machine. That type of function would need to be done through the
manufacturer's server. However, I do want to mention that there is a new--
it's called an FSS bulletin-- where IT is now acknowledged, as approved,
the use of wireless data transmission for PAP machines. And if the person
who asked that question would email me at [email protected], I will
send that FSS bulletin, which may be of help at your local VA. The FSS
bulletin, I should mention, is also posted on VA Pulse under sleep
medicine.
DENISE KENNEDY: Great. And we have more questions here coming in
for you. Will patient identification-- for example name, social security
number, et cetera-- be located on the vendor website? Or will it just be the
machine serial number, and REVAMP pulled from that serial number?
DR. SAMUEL KUNA: DME companies will not have access to the
REVAMP platform. So there will be personal health information and
identification on the platform, but again it is within the VA firewall, and has
gone through all of the VA privacy and security criteria regulations.
DENISE KENNEDY: Excellent. I’ll combine some questions here. The first
one is, when will it be available to all VAMCs? And the second one is, how
do we know if our center is part of the program? If not, is it possible to ask
to enter the program?
DR. SAMUEL KUNA: Well, we're certainly interested in people notifying us
that they're interested in participating. The process of getting REVAMP has
taken longer than we would have liked. We will have the pilot testing at 10
sites starting in March. We expect that will go through into the summer, and
then it will move into enterprise where the 10 VA medical centers will start
using it in routine practice. Our plan is that soon thereafter we will be
scaling it up and offering it to other VA medical centers.
I don't have a specific time schedule. Much of it is dependent on getting
through the regulatory aspects of the VA, but we've come a very long way,
and are optimistic that we're close to getting this out to at least the first 10.
DENISE KENNEDY: Excellent. Thank you. And more questions here, what
is the rate of technical difficulties faced by the patient in the pilot project so
far? Any insight into how patients are responding to the pilot?
DR. SAMUEL KUNA: So the initial pilot was done about two years ago at
Philadelphia and San Diego. We had very good feedback from the patients
about the use of the platform. We did not experience difficulties. Again,
we're selecting people who already have access to the internet, so they're
not coming in as completely naive. While that may exclude some people
from using the platform, we believe that as time goes on more and more
people are getting onto the mobile devices, and will have access to the
platform.
When we triaged patients-- so someone asked previously, how did you find
the patients-- when we triaged the patients, and asked them if they had
access to the internet through any kind of device. Eighty percent of the
people said they had access. We were very gratified with that and don't feel
there's a significant digital divide because of the fact that most people now
have an iPhone, an iPad, or some other mobile device that allows them
access.
DENISE KENNEDY: Excellent. Thanks. Okay, so are you working to have
information plus connections to the program available on the My
HealtheVet website?
DR. SAMUEL KUNA: We have certainly discussed the value of having an
interface on My HealtheVet. We do not have that at this time. It makes a lot
of sense to me that there would be a connection, but currently the two are
not communicating with one another.
DENISE KENNEDY: Great. Thanks. And we have a specific question here
from a listener. Their center had no HST and has an eight bed lab. Cloud
Follow Up and TeleSleep are used for follow up. How do you envision this
would affect their set up?
DR. SAMUEL KUNA: I see it as something that will allow them to collect
more information from the patient by having the patient provide a great deal
of details through validated questionnaires. And that it would improve their
staff efficiency. So that type of a sleep center doesn't have to use HST.
They can stick with their in laboratory testing if that's what they're
comfortable with and they have the resources to do that.
But now with REVAMP they can start looking at outcomes. What CPAP
adherence do our patients have? How does that compare with their results
on the functional outcome of sleep questionnaire? How does it compare
with the Epworth Sleepiness Scale, and the changes that they see on
CPAP treatment? All of these things they'll be able to generate in reports
exported out from the platform to track the quality of care at their center.
DENISE KENNEDY: Excellent. Thank you. And we're in the homestretch of
questions here. How do we negotiate mask fitting and patient instructions
using this platform?
DR. SAMUEL KUNA: So if the patient is remote from the sleep center, and
is having trouble traveling in, there would have to be some arrangement
made with the DME company-- or respiratory therapy at a local VA-- in
order to provide that type of service. Some of it might be done through
video teleconferencing, but I do think that an in-person interaction with the
CPAP set up is something that is very important. So there would have to be
some strategy that's developed in order to allow the patient to get delivery
of the equipment, instructions on how to set it up, and fitting for the mask.
DENISE KENNEDY: Great. Thank you. And when does the patient in the
REVAMP program see a physician or provider for follow up?
DR. SAMUEL KUNA: It depends on the clinical practice at the center itself.
The patient would be filling out questionnaires on the platform electronically
to indicate what type of response they've had; symptoms that have
improved; difficulties they are having; what's their Epworth score; what's
the change in their functional outcome of sleep questionnaire score? That
information would then be available to the practitioner when they are
visiting with the patient. Now, that visit could be in person, it could be by
phone, or it could be by clinical video teleconferencing. It's however the
sleep laboratory arranges to do that type of follow up. But at that visit they
would have the information not only from the questionnaires, but also from
the PAP data.
DENISE KENNEDY: Excellent. And final two questions here. The first one
is, will individual sites be able to put out individual questionnaires?
DR. SAMUEL KUNA: We have built in capabilities for that to occur. Yes. So
again, we realize that each site has particular preferences and particular
needs. So what we've done in REVAMP is that we have a core set of
questionnaires that we would like everyone to use to have a uniform data
collection across the VA. However, the sites would also have the option of
adding questionnaires at their site that they are familiar with-- that they've
been using-- that would be helpful to them for managing the patient.
DENISE KENNEDY: Great. And I believe this is our last question today.
Can patients who have had in-lab studies, and started on PAP, be added
into REVAMP for follow up purposes?
DR. SAMUEL KUNA: We are planning to do that. Currently the way the
platform is configured, it's to bring patients in who are just starting out --
who have not yet been diagnosed -- and they will start at the beginning. We
have recognized that as this platform matures we would want to bring in
people who are already on positive airway pressure. For example, people
who have been diagnosed outside- VA care and are transferring their care
to the VA. They may not need any kind of testing and they're just going to
be followed for their PAP treatment -- we want to allow those patients to
also use the REVAMP platform.
It's on our items to develop, but currently the platform is designed for
patients who are newly referred for diagnosis and evaluation of sleep
apnea.
DENISE KENNEDY: Excellent. And before we do our last final wrap up,
any parting words, Dr. Kuna? I know you've been talking for a solid 40
minutes.
DR. SAMUEL KUNA: Well, I'm very excited by the questions. They're right
on. We have accomplished a great deal in the work that we've done, and
we're really looking forward to seeing this go into production. And believe
me, we're trying to get this moving as fast as we possibly can, so that the
people who have expressed so much interest in it will have access to it as
well.
DENISE KENNEDY: Excellent. And thank you so much to both of you for
this presentation today. For everyone who is still with us, on screen there is
a feedback link. Please let us know what you thought of today's
presentation, and if you have any other suggestions for presentations in the
future.
If I missed your question, I'm going to keep the chat box open for a couple
minutes here. Please go ahead and use that, and we will make sure to
follow up with Dr. Kuna directly. And also Harold, who's been running this
from behind the scenes-- thank you so much, Harold-- has put Dr. Kuna's
email in the chat box as well.
So with that, I hope everyone has a great rest of your day today, on Friday,
and a great weekend. Thanks so much, all, and with that we'll sign out.